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					Understanding
Food Poverty
An examination of food poverty and the underlying causes of this problem in
local areas, with a focus on rural and urban differences in food poverty
occurrence.




                                                       Sarah Jane Flaherty

                                                          September 2009
Introduction and Definition of Food Poverty

       The link between poor nutrition and ill-health has long been established. It is
estimated that poor nutrition is a contributory factor in one third of all cancers1; nearly 30% of
deaths from coronary heart disease2; and 30% of years of life lost due to disability or early
death3 in developed countries. Approximately seventy thousand deaths could be avoided in
the UK annually if the public consumed diets that adhered to the nutritional guidelines as set
out by the state4 and it is estimated that two billion pounds are spent each year within the
NHS treating diet-related illnesses5. Improvements in dietary intake would have significant
benefits to the health of the population and society as a whole.

       If a household or individual are unable to obtain a nutritionally adequate diet, they are
typically considered to be living in food poverty. Food poverty has also been defined as
those households that “do not have enough food to meet the energy and nutrient needs of
all of their members6.

       Food security is another term that is often used in this subject area, and has been
defined by the World Health Organisation as “when all people, at all times, have access to
sufficient, safe and nutritious food to meet their dietary needs and food preferences for an
active and healthy life”. Thus, individuals living in food insecure households are unable to
meet these criteria.

       This report aims to further examine food poverty and detail some of the underlying
causes for this problem. It will also examine specific issues related to accessibility of healthy
food in a local area, which is an important factor in the occurrence of food poverty. It is
hoped that this will increase the understanding of food poverty occurrence in a community,
and support the planning of public health initiatives to address this problem in local areas.




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What are the causes of food poverty?

       While a number of factors can contribute to the occurrence of food poverty, there are
typically believed to be four main influences: affordability of healthy food items, awareness of
what constitutes a healthy diet; availability of healthy food in a local area; and accessibility to
food outlets selling healthy food.

       Higher costs of healthy food items are often cited as a barrier to consuming a
healthier diet. Evidence has shown that a healthy diet, with adequate fruit and vegetables, is
more expensive than a diet that is based mainly on foods that are considerably higher in fats
and sugars7. It has also been reported that food items typically considered to be healthy are
often more costly in more deprived areas compared to more affluent areas8.

       The cost of shopping locally is also reported to be greater when compared to
shopping at larger supermarkets. The cost of a diet that adhered to nutritional
recommendations was examined in different areas, and it was shown that purchasing food
items to meet this diet was 88% more expensive in small local shops compared to the same
items at an out-of-town supermarket9. Many deprived communities rely heavily on local
shops as they cannot readily access out-of-town supermarkets, illustrating clear inequalities
in the affordability of healthy food items for this population group.

       There are strong links between knowledge of healthy eating and dietary intake.
Dietary knowledge is significantly associated with the consumption of a healthier diet, even
after adjusting for other demographic variables10. An increase in awareness of dietary
recommendations has been reported as a strong predictor of change to a healthier diet11.

       While the general population is typically aware of the recommendations for a healthy
diet, a number of population groups have been identified where this knowledge is typically
lower12. Males, lower socioeconomic groups and young people aged 16-25 were “less
oriented towards healthy eating in terms of their attitudes, awareness, and claimed
behaviour”12, as identified by the Food Standards Agency Consumer Attitudes Survey.

       Accessibility and availability of healthy foods in a local area are important factors in
the occurrence of food poverty in a household. Reasonable physical access to food outlets is
deemed to be a walking distance of 500 metres or less13, which represents a walking time of
approximately ten minutes for the average person. This will obviously differ depending on
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the circumstances e.g. older adults are likely to take a longer time, and longer travel times
are also expected in those areas with steep gradients. It is important to take into account the
different population groups resident in an area when assessing food poverty in a local area.

        There has been an increase in the development of out-of-town supermarkets in
recent times and a reduction in the number of shops operating in local areas, especially in
socially deprived communities. Between 2001 and 2007, 29% of local independent food
outlets closed for business14. This can be an important factor for those population groups
that rely heavily on accessing food outlets in their local area, e.g. older adults and individuals
with mobility problems. This problem is compounded further in certain areas due to a lack of
adequate and accessible public transport to access alternative food outlets.

        This highlights the complex nature of food poverty, and the multiple factors that can
interact to lead to its occurrence within a household. All factors need to be considered when
examining this issue within a local area, as it is likely that one factor will not be the sole
cause of food poverty. All of the above issues must be considered and addressed in the
planning of public health initiatives for effective action against food poverty.




Who is at risk of living in food poverty?

        The Food Poverty Toolkit15 was developed by the National Heart Forum with the aim
of supporting local health professionals in developing strategies and action plans to improve
the nutrition of those living in food poverty.

        This toolkit identifies a number of population groups as those most likely to be at risk
of food poverty. It is mainly those groups who are heavily reliant on accessing food in their
local area, either due to an inability to utilise private or public transport or inadequate access
to such transport, that are seen to be at risk. Low-income groups and those that are
unemployed or living on benefits are at risk of food poverty, as are older adults and
individuals with disabilities or reduced mobility. Households with dependent children and
members of black and minority ethnic communities are also cited as being at risk of food
poverty.



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        The Low Income Diet and Nutrition Survey16 reported that 29% of the study
population were considered to live in food insecure households, as access to sufficient
amounts of food was limited at some time during the previous year. Within this low income
group, food insecurity was reported more often for working adults living alone and for
households containing one adult and one or more children, but food insecurity was reported
least often in households of retired adults.




What are the links between poor accessibility and healthy diet?

        There is debate within the literature on how strongly dietary intake is influenced by
accessibility to healthy food in a local area, but some studies have identified a link between
inadequate accessibility to healthy food and poor dietary intake.

        A study undertaken in Newcastle17 found that knowledge and awareness about
healthy eating were the most important predictors of achieving a healthy diet in the total
study population. Subsequent analysis identified a specific sub-group of residents that did
not have adequate access to private or public transport and who shopped mainly in their
local area. In this sub-group, availability of fruit and vegetables in their local area and
distance to their main food outlet were reported as being strong predictors of a healthy diet,
although knowledge and awareness of a healthy diet were still seen to have a significant
influence. It was reported that this population group had poorer dietary intake in comparison
to other groups and lower intakes of fruit and vegetables.

        The Low Income Diet and Nutrition Survey16 (LIDNS) reported similar patterns where
females that were able to access larger supermarkets reported higher intakes of fruit and
vegetables than women living in households that relied on local shops as their main food
outlets. However, few other significant differences in dietary intake were seen based on the
main food outlet used for regular shopping. While this does not illustrate a definite link
between accessibility and dietary intake it does suggest that those communities that do not
have adequate access to healthy food are likely to consume poorer diets.

        While a consensus has not been reached on the level of influence that accessibility
has on dietary intake, it is clear that it is an important factor in achieving a healthy diet for


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specific population groups. However, further evidence is required to better understand this
relationship and its importance in the promotion of healthy eating.




Rural and Urban Differences in Food Poverty

       Poor accessibility and availability of healthy food items are reported to be problems in
both rural and urban areas, but different causal factors are believed to be important in each
area type. Accessibility is generally believed to be worse in more rural areas18 due to a lower
number of food outlets and less frequent public transport services, but a lack of substantial
evidence available on this issue makes it difficult to determine if this is indeed the case.

       A study undertaken in Scotland19 on behalf of the Food Standards Agency Scotland
found no clear relationship between availability of healthy foods and the rural-urban indicator
used in the study, although some clear differences were seen between area types. It was
reported that food outlets in rural areas were more geographically dispersed than in urban
areas. However, while there was a higher dependence on smaller outlets in these local
areas; these food outlets usually had a wide range of foods available. Thus, while there is a
fewer number of food stores in rural areas, this was not always associated with reduced
availability. It is important to note that rural residents still needed to travel longer distances
than in urban areas to access food outlets, which may pose a problem for certain population
groups, e.g. older adults and individuals with reduced mobility.

       A different picture was reported for urban areas in this study, where there was
generally a higher density of small food outlets but a smaller range of healthy items available
in each outlet. Thus, individuals would be required to visit more than one food outlet to
purchase sufficient food items to achieve a healthy diet in urban areas.

       A study undertaken in Staffordshire10 also found that it was possible to purchase
enough fruit and vegetables to achieve the nationally recommended five portions a day
regardless of urban or rural location. This study reported that poor accessibility was an issue
in both rural and urban areas but that the underlying causes were specific to each area type,
illustrating a need to address food poverty differently in urban and rural areas.



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       Studies have not reported significant differences in the cost of a healthy diet11
between urban and rural areas although an association has been identified between
deprivation and the cost of healthy foods in rural areas. It was found that healthy foods were
more expensive in more deprived rural areas, but this pattern is not prevalent in deprived
urban areas. This suggests that the level of deprivation may not be as strong a predictor of
food poverty in urban areas as it appears to be for rural areas.

       It has also been reported that larger supermarkets are the least expensive outlet to
purchase healthy foods, with the smaller general stores as a more expensive option 10 19. As
it has been previously shown that certain population groups in rural areas may be ‘forced’ to
shop in these smaller food outlets on a regular basis, it is possible that shopping in a rural
area may be more costly for these population groups than similar communities in urban
areas. This is also true for a number of studies undertaken in the US, where it was reported
that communities in rural areas that relied   heavily   on   small   or    convenience   stores
                                                                                    20 21
experienced higher food prices than those able to shop in larger supermarkets            . This
suggests that poor access to healthy and affordable foods is a problem in both urban and
rural areas, but the underlying causes can differ according to location.




Sustainability of the Food Supply

       The sustainability of the existing food supply in the UK is becoming an increasingly
important issue in the area of food poverty and access to healthy food. Recent concerns
have been voiced about the vulnerability of the food supply in the UK and an over-
dependence on imports, but the recent DEFRA report entitled UK Food Security
Assessment22 has dispelled these concerns stating that the UK is “very resilient in terms of
disruptions from one or a few sources of supply” and that these favourable conditions will
remain over the next five to ten years.

       Despite this, it is important to consider sustainability issues in local food and health
plans as there are potential impacts on food availability and affordability. A reliance on
imported food stocks leaves the UK population open to changes in food prices in other
countries. Global food prices have drastically increased in recent years which have impacted
on the purchasing behaviours of poorer populations, including in the UK. If such increases

                                                                                             6
continue, as predicted by some organisations4, this could have a real impact on the ability of
specific population groups to purchase a healthy diet.

        In addition, the UK is heavily reliant on other countries to supply sufficient amounts of
fruit and vegetables for the population. If intakes of these foods were to increase to reach
recommended daily intakes, the level of imports would also need to be increased or UK
production levels would need to drastically improve4.

        The sustainability of the UK food supply is a complex issue which relies as much on
international farming and trade policies as it does on current national strategies. It cannot be
solved in local food and health plans as much is dependent on outside forces form both the
public and private sector. However, it is important to be aware of the concerns that are
present and the need to consider this issue in current plans to be best prepared for future
challenges.




Measuring Food Environments

        It is well established that the environment in which one resides has an impact on
personal health, but it is now clear that the food environment in which one resides may also
play a role. There is a need to determine the key elements in the local food environment that
impact on dietary intake, in order to influence this environment to support a change to a
healthier diet.

        McKinnon et al23 completed a search of the different methods that have been used to
examine food environments and identified a number of different methodologies and
instruments. The most common methodology identified was the use of geographic analysis.
This method of analysis uses data from specific geographic measures and assesses the
food environment based on diversity, proximity or variety of outlets, depending on the
research question. Other methodologies used to measure the food environment included
sales and nutrient analyses, which were mainly used to determine the availability of specific
foods in a local area and the nutrient content of the foods available.

        This report also examined the different types of instruments that have been used to
assess the observed or perceived food environment. Interviews and questionnaires were

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identified as the most common instrument used in assessing food environments, and this
was followed by market baskets, checklists and inventories. This highlights the diverse range
of techniques available for measuring food environments. All of these instruments examine
different aspects of the food environment, thus providing slightly different information on the
area in question.

       The East Midlands Public Health Observatory (EMPHO) has developed a toolkit
which examines some of the different tools and methods that are available for measuring
local food environments. For further information on this toolkit, please see the EMPHO
website (www.empho.org.uk).




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References:

1
 Department of Health. Nutritional Aspects of the Development of Cancer. Report on Health and
Social Subjects No. 48. 1998.
2
 Peterson S, Rayner R. Coronary Heart Disease Statistics. British Heart Foundation Statistics
Database 2003. London: British Heart Foundation; 2003.
3
 World Health Organisation. World Health Report 2002: Reducing Risks, Promoting Healthy Life.
Geneva: World Health Organisation; 2002.
4
    Cabinet Office - The Strategy Unit. Food Matters. Towards a Strategy for the 21st Century. 2008.
5
 Department of Health. Choosing a Better Diet: A Food and Health Action Plan. London: Department
of Health; 2005.
6
 DeRose L, Messer E, Millman S. Who's hungry? And how do we know? Food shortage, poverty, and
deprivation. New York: United Nations University Press; 1998.
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 Drenowski A, Darmon N. Diet Choices and Food Costs: an economic analysis. Journal of Nutrition.
2005;135:910-912.
8
  Sooman A, Macintyre S, Anderson A. Scotland’s health: a more difficult challenge for some? The
price and availability of healthy foods in socially contrasting localities in the West of Scotland. . Health
Bulletin (Edinburgh). 1993;5:276-284.
9
    O' Neill M. Putting food access on the radar. London: National Consumer Council; 2005.
10
  Parmenter K, Waller J, Wardle J. Demographic Variation in Nutrition Knowledge in England. Health
Education Research. 2000;15(2):163-174.
11
   Van Duyn M, Kristal A, Dodd K, Campbell M, Subar A, Stables G. Association of awareness,
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12
   Food Standards Agency. Consumer Attitudes to Food Standards: Wave 8.                     London: Food
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13
  Donkin A, Dowler E, Stevenson, S, Turner S. Mapping access to food at a local level. . British Food
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14
     http://www.fooddeserts.org/
15
  Press V, Mwatsama M. Nutrition and Food Poverty. A toolkit for those involved in developing or
implementing a local nutrition and food poverty strategy. London: National Heart Forum; 2004.
16
  Nelson, M., Erens, B., Bates, B., Church, S., and Boshier, T. Low Income Diet and Nutrition Survey.
London: The Stationery Office, 2007.



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17
   University of Newcastle. Do food deserts exist? A multi-level, geographical analysis of the
relationship between retail food access, socio-economic position and dietary intake. London: Food
Standards Agency; 2004.
18
     O' Neill M. Putting food access on the radar. London: National Consumer Council; 2005.
19
  Dawson J, Marshall D, Taylor M, Cummins S, Sparks L, Anderson A. Accessing Healthy Food: A
Sentinel Mapping Study of Healthy Food Retailing in Scotland. London: Food Standards Agency;
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20
   Bustillos BD, Sharkey JR, Anding J, McIntosh A. Availability of healthier food alternatives in
traditional, convenience, and nontraditional types of food stores in two rural Texas counties. J Am Diet
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21
  Morton LW, Bitto EA, Oakland MJ, Sand M. Solving problems of Iowa food deserts: food insecurity
and civic structure. Rural Sociol 2005;70: 94–112.
22
  Department for Environment, Food and Rural Affairs (DEFRA). UK Food Security Assessment: Our
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  McKinnon R, Reedy J, Morrissette M, Lytle L, Yaroch A. Measures of the Food Environment. A
Compilation of the Literature, 1999-2007. American Journal of Preventive Medicine.
2009;36(4S):S124- S133.




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